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Rule Out/ Suspected DX

  1. #1
    Default Rule Out/ Suspected DX
    Medical Coding Books
    When billing for a physician's in patient evaluation and management services, can you use rule out or suspected diagnoses codes for the visit? I am getting conflicting reports. It is my understanding that you code to the highest degree of certainty. However, there seems to be some variation when it comes to billing in the in patient setting. Can someone offer further clarification?
    Last edited by heatherwinters; 02-03-2009 at 12:49 PM.
    Heather Winters, CPC, CFPC

  2. #2
    North Carolina
    Do not code from "probable", "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. If a definitive diagnosis is not known upon the completion of the service, the diagnosis should be listed as the symptoms, signs, abnormal test results, or other reason for the visit.

    I just noticed the word inpatient...I'm mostly provider based but, correct me if I'm wrong... In the inpatient setting, if a diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "rule out," the condition should be coded as if it existed or was established. The basis for this guideline are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
    Last edited by RebeccaWoodward*; 02-03-2009 at 01:01 PM.
    Rebecca CPC, CPMA, CEMC

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  3. #3
    Default In Patient
    There in lies the question. When a provider does his rounds, can I use the suspected dx for icd-9 codes on that day?
    Heather Winters, CPC, CFPC

  4. #4
    Jacksonville, FL River City Chapter
    For provider-based coding, you always operate under the rule that says do not bill for probable/suspected/rule-out conditions, whether the service was provided to an inpatient or outpatient.

    Seth Canterbury, CPC, ACS-EM

  5. Smile guidelines for supspected coding
    Does the same rule appy for ICD 10 coding for suspected conditions?

  6. #6
    Baton Rouge
    Quote Originally Posted by Beauty23 View Post
    Does the same rule appy for ICD 10 coding for suspected conditions?
    Yes. This applies for all physician coding--cannot use suspected symptoms. This did not change with ICD10.
    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

  7. #7
    Columbia, MO
    The rule for coding uncertain diagnosis is... If you are coding for the facility you code the uncertain dx as thought it exists. However when coding for outpatient or physician coding you do not code the uncertainty. The facility rule only applies to those coding for facility reimbursement. For physician coding you always follow the physician rule regardless of the place of service.

    Debra A. Mitchell, MSPH, CPC-H

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